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We welcome the recent article examining the cost-effectiveness of
pulse oximetry screening for newborns. Implementing a new screening
programme creates ongoing operating costs and start up costs. The model
for their cost effectiveness analysis was based on a previous model
described by Knowles et al, which based the cost of echocardiography on
provision by a senior radiographer.
Ewer et all calculated a s...
Ewer et all calculated a sensitivity of 49% and specificity of 99.16%
for major cases through use of pulse oximetry screening. For units
delivering 5000 babies a year, assuming a CHD rate of 2/1000, this equates
to identifying five cases though screening and subsequent
echocardiography, missing five cases that the screen did not pick up, and
performing echocardiography on another 45 babies picked up by the screen
that did not have major congenital cardiac disease. This unit should have
resource to provide approximately one more urgent echocardiograph per
week, although this may be higher in tertiary units where referral
patterns could double demand. Scans would need to occur urgently to
exclude disease requiring urgent surgical intervention.
Only a few people working in tertiary level neonatal units usually
have the skills to perform a diagnostic echocardiograph, typically
consultant paediatric cardiologists or neonatologists. Requirements for
performing adequate echocardiographs on neonates have been discussed
extensively in the literature with the focus of discussion being whether
cardiologists or neonatologists are the most appropriate providers[4,5].
The issue of radiographers performing scans is not well covered in the
literature. A detailed knowledge of foetal and neonatal cardiac anatomy is
necessary to perform scans; any new service designed around provision by
senior radiographers will need to consider the extensive retraining
Providing cover by training a full rota of senior radiologists is
unlikely to be the best option for providing the new service. An average
unit would not be performing sufficient scans to maintain their skills. It
is more likely that the burden will fall on the existing providers. The
most likely conclusion is that providing this screening programme will
require that the majority of consultant neonatologists are trained in
echocardiography and that they maintain their skills through adequate
numbers of scans a year.
The proposed reconfiguration to children's congenital cardiac
services, currently on-going at national level, will have important
implications and the introduction of pulse oximetry will need to be
carefully integrated into the proposed model of care. Further, whilst the
NHS cost implications are important, work is required to consider the
needs of the families affected. Some may be required to travel further to
centres to receive echocardiography because of geographical location to a
centre, or simply through giving birth at home. Telemedicine links to
major cardiac units may address these issues in the long term. These costs
also need consideration.
1 Roberts TE, Barton PM, Auguste PE, et al. Pulse oximetry as a screening
test for congenital heart defects in newborn infants?: a cost-
effectiveness analysis. Archives of Disease in Childhood Published Online
First: 2012. doi:10.1136/archdischild-2011-300564
2 Knowles R, Griebsch I, Dezateux C, et al. Newborn screening for
congenital heart defects: a systematic review and cost-effectiveness
analysis. Health Technol Assess 2005;9:1-152.
3 Ewer AK, Middleton LJ, Furmston AT, et al. Pulse oximetry screening for
congenital heart defects in newborn infants (PulseOx): a test accuracy
study. The Lancet 2011;6736:21-3.
4 Ward CJ, Purdie J. Diagnostic accuracy of paediatric echocardiograms
interpreted by individuals other than paediatric cardiologists. Journal of
paediatrics and child health 2001;37:331-6.
5 Moss S, Kitchiner DJ, Yoxall CW, et al. Evaluation of echocardiography
on the neonatal unit. Archives of disease in childhood Fetal and neonatal
edition 2003;88:F287-9; discussion F290-1.
Matthew S Day is the chairperson of the Congential Cardiac Network Board Working Group on Pulse Oximetry